WLD-05 (05-05) DEPARTMENT OF REVENUE LIQUOR DIVISION NEW RENEWAL Rec'd application: Rec'd cash/check: 1520 East 5th Street Cheyenne, WY 82002-0500 Reviewed by: APPLICATION for Class “C” INDUSTRY REPRESENTATIVE LICENSE LICENSED EVENT: EVENT TERM: From: / / To: / / Applicant Residence Address City State Zip Mailing Address City State Zip Business Name Home Phone: 1. Are you 18 years of age or older? Yes 2. Are you domiciled in Wyoming? Yes Business Phone: No No 3. (a) Do you presently hold any interest (directly or indirectly) in any type of retail liquor license or retail malt beverage permit within the State of Wyoming? Yes No (b) If "Yes," please attach a full explanation. 4. (a) Have you been convicted of a felony or a violation of federal or state statutes relating to sale or manufacture of alcoholic beverages in the ten (10) years preceding this application? Yes No 5. Have you ever had a liquor or industry representative license denied, canceled, suspended or revoked? Yes If "Yes," please attach a full explanation. No 6. (a) List below the company represented by your Class “A” Industry Representative sponsor. COMPANY ADDRESS EMPLOYMENT/CONTRACTUAL ARRANGEMENT (b) Please attach written verification from the Class “A” Industry Representative of the company indicated above. 7. I have read and understand the laws and rules of the State of Wyoming regarding the advertisement and promotion of alcoholic beverages and will abide by these laws and rules. I understand that violation of these laws and rules may constitute cause for denial, suspension or revocation of my license. _________________________________________________ _____________________ Signature Date ________________________ $10.00 FEE IS DUE WITH APPLICATION FOR EACH EVENT American LegalNet, Inc. www.FormsWorkflow.com